1093891871 NPI number — MS. PATRICIA GALE WALLERSTEIN MSW LICSW

Table of content: MS. PATRICIA GALE WALLERSTEIN MSW LICSW (NPI 1093891871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093891871 NPI number — MS. PATRICIA GALE WALLERSTEIN MSW LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLERSTEIN
Provider First Name:
PATRICIA
Provider Middle Name:
GALE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093891871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 10TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-463-6901
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
AMESBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-388-5311
Provider Business Practice Location Address Fax Number:
978-388-5571
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1022652 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102265 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: PP0352 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1890247 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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